JACC: CARDIOVASCULAR IMAGING VOL. 4, NO.

10, 2011

© 2011 BY THE AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION ISSN 1936-878X/$36.00

PUBLISHED BY ELSEVIER INC. DOI:10.1016/j.jcmg.2011.08.008

Left Atrial Function and Mortality in

Patients With NSTEMI
An MDCT Study

J. Tobias Kühl, MD, MA,* Jacob E. Møller, MD, DMSC,* Thomas S. Kristensen, MD, PHD,†
Henning Kelbæk, MD, DMSC,* Klaus F. Kofoed, MD, DMSC*†
Copenhagen, Denmark

O B J E C T I V E S We sought to test the hypothesis that measures of left atrial (LA) function are
independent predictors of mortality in patients with acute myocardial infarction.

B A C K G R O U N D Left atrial maximal volume (LAmax) is known to predict mortality in patients with
acute myocardial infarction. In a previous pilot study, however, we found that LA function in terms of
fractional change and left atrial ejection fraction (LAEF) assessed by multidetector computed tomogra-
phy (MDCT) is more closely related to clinical heart failure than LAmax.

M E T H O D S We prospectively included 384 patients presenting with non–ST-segment elevation

myocardial infarction (NSTEMI) who underwent retrospectively gated, 64-slice MDCT coronary angiog-
raphy and subsequent measurements of LA size and function. All patients were treated according to the
current guidelines based on invasive coronary angiography. Patients were followed for a minimum of 2
years. The study endpoint was all-cause mortality.

R E S U L T S The median follow-up time was 36 months (range 10 to 1,551 days). During follow-up, 35
(9%) patients died. Overall, 1- and 2-year survival in the study cohort was 97% and 94%. LA size and
mechanical function was obtained in all patients: mean LAmax was 55 ⫾ 11 ml/m2, LA minimal volume
31 ⫾ 11 ml/m2, fractional change 45 ⫾ 9%, and LAEF 32 ⫾ 9%. Using a Cox proportional hazards model
with adjustments for age, number of diseased coronary vessels, left ventricular ejection fraction (LVEF),
and Killip class, both fractional change (hazard ratio [HR]: 0.65; 95% confidence interval [CI]: 0.45 to 0.94)
and LAEF (HR: 0.63; 95% CI: 0.44 to 0.91) remained independent predictors of mortality. In contrast to
this, LAmax was not significantly associated with an increased risk of mortality in this population.

C O N C L U S I O N S In a low-risk group of patients with NSTEMI, reduced LA function is an

independent predictor of mortality and provides prognostic value incremental to that of LAmax. (J Am
Coll Cardiol Img 2011;4:1080 –7) © 2011 by the American College of Cardiology Foundation

From the *Department of Cardiology, the Heart Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark;
and the †Department of Radiology, Diagnostic Centre, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
The study was supported by the John and Birthe Meyer Foundation and Michaelsen Fonden (Copenhagen, Denmark). All
authors have reported that they have no relationships relevant to the contents of this paper to disclose.
Manuscript received August 12, 2011; accepted August 19, 2011.
JACC: CARDIOVASCULAR IMAGING, VOL. 4, NO. 10, 2011
OCTOBER 2011:1080 –7
T
he left atrium (LA) acts as a reservoir and
conveys blood from the pulmonary vascular
bed to the left ventricle. The left atrial maxi-
mal volume (LAmax) is determined by mul-
tiple factors, including the pressure gradient across
the mitral valve in early diastole, left ventricular
(LV) chamber compliance, LA active contraction,
and intrinsic LA wall factors. It is believed that the
LA will dilate in response to either volume or
pressure overload (1–3). In agreement with this,
several studies have demonstrated that LA dilation
is associated with increased morbidity and mortality
in patients with acute myocardial infarction and
cardiomyopathy (4 – 6). However, the LA modu-
lates blood flow to the left ventricle in a complex
manner, and measurements of LAmax may only
partially reflect the prognostic implications of volume
or pressure overload of the chamber. Multidetector
computed tomography (MDCT) with high spatial
and temporal resolution has been shown to be suitable
for a more elaborate description of LA function (7,8).
We have recently reported that LA fractional
change (difference between maximal and minimal
LA volume) and left atrial ejection fraction (LAEF)
were more closely related to clinical signs of heart
failure than LAmax measured with MDCT in a
group of patients with coronary artery disease (8). Based
on this observation, we hypothesized that decreased LA
function assessed with MDCT is an independent pre-
dictor of adverse outcome in patients with acute coronary
artery disease, and is incremental to LAmax.
In the current study, we therefore tested the hy-
pothesis that MDCT measures of LA function pre-
dict outcome in patients with a recent non–ST-
segment elevation myocardial infarction (NSTEMI).
METHODS
Between December 2006 and January 2009, consec-
utive patients (n ⫽ 1,409) with NSTEMI, referred for
invasive coronary angiography at Copenhagen Uni-
versity Hospital Rigshospitalet, were screened for
participation in the study. NSTEMI was defined
according to guidelines (9) as symptoms with acute
chest pain and/or electrocardiographic changes with-
out persistent ST-segment elevation and with a char-
acteristic rise and fall in serum troponin T. Patients were
scanned with MDCT prior to the invasive procedure as
part of a research project. Patients with contraindication
to MDCT, history of chronic renal disease or elevated
plasma creatinine (⬎125 ␮mol/l, n ⫽ 157), history of
atrial arrhythmias or arrhythmia during MDCT (n ⫽
59), known allergy to iodine contrast (n ⫽ 5), hemody-
Kühl et al. 1081
Prognostic Value of Left Atrial Function
namic instability (n ⫽ 18), mitral insufficiency (n ⫽ 7),
and refusal to participate (n ⫽ 76), were not enrolled in
the study. Due to logistical reasons, 699 patients were not
enrolled, primarily due to absence of scanner availability
or coincidence with the invasive procedure. After enrol-
ment of 388 patients, 4 had to be excluded because they
could not be in follow-up due to nonresidency. Accord-
ingly, the final study population consisted of 384 patients
(Fig. 1). The study was approved by the local ethics
committee, and informed consent was obtained from all
patients.
MDCT and invasive coronary angiography were
performed in all included patients. Treatment strat-
egy was decided by the interventional cardiologist
according to international guidelines, blinded to
MDCT findings (9).
Previous medical history and cardiovascular risk profile
of the patients was recorded from hospital
charts. Clinical signs of heart failure within 5 ABBREVIATIONS
AND ACRONYMS
days prior to MDCT were recorded according
to the Killip class. AUC ⴝ area under the receiver-
The endpoint of the study was death operator characteristic curve
from all causes. Vital status of included CC ⴝ cyclic change
patients was recorded for a minimum of 2 LA ⴝ left atrium
years after inclusion from electronic data- LAEF ⴝ left atrial ejection
bases containing vital status in Denmark fraction
(Green System, CSC Scandihealth) and LAmax ⴝ left atrial maximal
the Faroe Islands (Cambio COSMIC reg- volume
istry). LAmin ⴝ left atrial minimal
Multidetector computed tomography. All volume
patients were scanned using a 64-slice LASV ⴝ left atrial stroke volume
MDCT scanner (Toshiba Aquillion, LV ⴝ left ventricular
Toshiba Medical Systems Corporation, MDCT ⴝ multidetector
Otawara, Japan) prior to angiography computed tomography
and/or intervention with the following NSTEMI ⴝ non–ST-segment
elevation myocardial infarction
parameter settings: tube voltage 120 to
135 kV depending on body mass index,
detector collimation 64 ⫻ 0.5 mm, and rotation
time between 350 ms and 500 ms depending on the
heart rate. Depending on expected scan time, 70 to
100 ml of contrast agent (Visipaque 320, GE
Healthcare, Chalfont St. Giles, United Kingdom)
was infused with a rate of 5 ml/s, followed by 30 ml
of 70:30 (%) contrast/saline mix, and then 30 ml of
pure saline chaser. Image acquisition was initiated
by automatic bolus triggering. The estimated radi-
ation dose was 14 to 20 mSv with use of retrospec-
tive gating and dose modulation. Raw data were
reconstructed in 5% intervals throughout the car-
diac cycle, with a slice thickness and increment of
2.0/2.0 mm. No additional beta-blocker or other
medication was administered prior to MDCT ex-
amination. All image data were transferred to an
1082 Kühl et al.
Prognostic Value of Left Atrial Function
Figure 1. Flow Chart of Patient Inclusion
Flow chart of patient inclusion, with reasons for exclusion and total number of patients in the study population. MDCT ⫽ multidetector
computed tomography.
external workstation (Vitrea 2, version 4.0, Vital
Images Inc, Minnetonka, Minnesota) for image
analysis blinded to clinical information.
Image analysis. LA volumes were measured as pre-
viously described (8), by tracing the endocardial
border on 15 to 20 tomographic slices— depending on
size and shape of the chamber— using axial view
images. The pulmonary veins were carefully excluded,
whereas the LA appendage was included in the LA
cavity. The software interpolated the endocardial seg-
mentation to calculate the volume. Volumes were
measured in 5% intervals during the RR cycle, and a
time–volume plot was generated for each patient.
LA reservoir function was assessed as cyclic
change (CC) (calculated as the difference between
LAmax and left atrial minimal volume [LAmin])
and fractional change (calculated as CC/LAmax).
LA passive emptying was assessed as reservoir
volume (calculated as the difference between
LAmax and the minimal mid-diastolic volume;
defined as the lowest point between LAmax and
“the LA volume immediately before atrial systole”)
and reservoir fraction (reservoir volume/LAmax).
LA active emptying was assessed as left atrial stroke
volume (LASV) (defined as the difference between
“LA volume immediately before atrial systole” and
LAmin) and LAEF (LAEF ⫽ LASV/“LA volume
just before atrial systole”).
Interobserver variability was assessed in 50 pa-
tients. Mean percentage error of LAmin was 1 ⫾
11%, of LAmax 3 ⫾ 9%, of fractional change 5 ⫾
11%, and of LAEF 2 ⫾ 19%. At our center,
agreement between assessment of LA size and
function between cardiac magnetic resonance im-
JACC: CARDIOVASCULAR IMAGING, VOL. 4, NO. 10, 2011
OCTOBER 2011:1080 –7
aging and MDCT has been assessed in 50 patients
with ischemic heart disease. Mean percentage error
was: LAmin 4 ⫾ 14%, LAmax 9 ⫾ 12%, fractional
change 2 ⫾ 13%, and LAEF ⫺3 ⫾ 20% (10).
LV end-diastolic volume, LV end-systolic vol-
ume, and left ventricular ejection fraction (LVEF)
were measured as previously described (11).
Statistics. Statistical analysis was performed using
SAS version 9.13 (SAS Institute, Cary, North
Carolina). Continuous variables are presented as
mean ⫾ SD and categorical variables as frequencies
and percentages. For statistical comparisons, a
2-tailed t test for independent samples was used for
continuous values and chi-square test was used for
categorical variables. Continuous variables that
were not normally distributed were compared with
Mann-Whitney U test. Chi-square test for trend
was used to test differences between ordered groups.
The relation between mortality and tertiles of
LAmax, LAmin, fractional change, and LAEF
was plotted according to the Kaplan-Meier
method, and death rates were compared by the
log-rank test. The relationship between MDCT
variables, clinical variables, and all-cause mortal-
ity was assessed using Cox proportional hazards
regression. First, a univariable analysis was per-
formed for potential LA predictors of clinical
events: LAmax, LAmin, fractional change, CC,
reservoir volume, reservoir fraction, LAEF, LASV,
and in addition, for age, sex, hypertension, LVEF,
number of diseased coronary vessels, Killip class,
diabetes, and previous myocardial infarction. Second,
multivariable regression analysis with forced entry of
LAmax, LAmin, fractional change, CC, LAEF, and
JACC: CARDIOVASCULAR IMAGING, VOL. 4, NO. 10, 2011
OCTOBER 2011:1080 –7
LASV was performed separately with adjustment for
established clinical predictors (age, LVEF, number of
diseased vessels, and Killip class ⱖ2). Finally, the
overall Wald chi-square of a model including LAmax,
age, LVEF, number of diseased vessels, and Killip
class ⱖ2 was compared with a model with the afore-
mentioned variables and either fractional change or
LAEF to assess the incremental information of LA
function. The proportional hazard assumption was
checked through the method of cumulative residuals.
The discriminative power of LA size and function
after 2 years of follow-up was assessed by calculating
the mean of the area under the receiver-operator
characteristic curve (AUC). A p value ⬍0.05 was
considered statistically significant.
RESULTS
Demographic information of patients enrolled in
the study is given in Table 1. Patients screened for
participation in the study but not enrolled (n ⫽
1,025) were older (67 ⫾ 12 years vs. 61 ⫾ 12 years,
p ⬍ 0.001), had lower estimated glomerular filtra-
tion rate (76 ⫾ 38 ml/min vs. 87 ⫾ 20 ml/min, p ⬍
0.001), and were more likely to have diabetes (24%
Table 1. Demographics (n ⴝ 384)
Age, yrs
Female
Body mass index, kg/m2
Hypertension
Diabetes
eGFR
Smoker (current or former)
Previous myocardial infarction
Coronary artery disease
No significant stenosis
1-vessel disease
2-vessel disease
3-vessel disease
Left main disease
Left ventricular ejection fraction, %
Troponin T maximum, ng/ml
Killip class ⱖ2
Medication at discharge
Beta-blocker
ACE-inhibitor
AIIA
Aspirin
Clopidogrel
Statin
Values are mean ⫾ SD or n (%).
ACE ⫽ angiotensin-converting enzyme; AIIA ⫽ angiotensin II receptor
antagonist; eGFR ⫽ estimated glomerular filtration rate (calculated using the
Modification of Diet in Renal Disease formula).
Kühl et al. 1083
Prognostic Value of Left Atrial Function
vs. 16%, p ⫽ 0.001) and 3-vessel disease (26% vs.
21%, p ⫽ 0.03) than patients who were enrolled,
but did not differ with regard to other risk factors or
treatment strategy.
In all enrolled patients, LA size and function
could be assessed. Mean LAmax was 55 ⫾ 11
ml/m2, LAmin 31 ⫾ 11 ml/m2, fractional change
45 ⫾ 9%, and LAEF 32 ⫾ 9%.
In univariate regression analysis, LA volumes
were correlated with EDV index (LAmax: ␤ ⫽
0.26, p ⬍ 0.001, and LAmin: ␤ ⫽ 0.22, p ⬍ 0.001)
and inversely correlated with LA function (frac-
tional change: ␤ ⫽ ⫺0.08, p ⬍ 0.001, LAEF: ␤ ⫽
⫺0.09, p ⬍ 0.001).
All-cause mortality. The median follow-up time
was 36 months (range 10 to 1,551 days). During
follow-up, 35 (9%) patients died. Overall, 1- and
2-year survival in the study cohort was 97% and
94%, respectively, which was significantly higher
than the 1- and 2-year survival among patients
excluded from the study (89% and 84%, respec-
tively, p ⬍ 0.001).
In the study cohort, surviving patients were
characterized by lower age, lower prevalence of
3-vessel or left main disease, higher LVEF, and
lower Killip class (Table 2). Mortality according to
tertiles of LA size and function is presented in
61 ⫾ 12 Figure 2. High LAmin was associated with poor
92 (24) survival, whereas there was no significant difference
28 ⫾ 5 between LAmax tertiles using log-rank statistics.
191 (50) Poor LA function (reduced fractional change and
61 (16) LAEF) was associated with adverse outcome.
87 ⫾ 20
In a univariate Cox regression analysis, the sig-
285 (74)
nificant LA predictors of all-cause mortality were
85 (23)
LAmin, fractional change, CC, LAEF, and LASV
(Table 2). LAmax, LAmin, fractional change, CC,
67 (17)
LAEF, and LASV were separately included in
138 (36)
98 (26)
separate multivariate Cox regression models with
79 (21)
forced entry of a priori known predictors of mortality
21 (5) including: age, LVEF, number of diseased vessels, and
58 ⫾ 12 Killip class ⱖ2. In those models, fractional change, CC,
0.84 ⫾ 1.30 LAEF, and LASV remained independent predictors of
45 (12) all-cause mortality, whereas LA size was no longer
significant (Table 3).
319 (83) The overall Wald chi-square of a model including
107 (28) LAmax, age, Killip class, LVEF, and number of diseased
34 (9) vessels was 38.00. If fractional change was added to this
370 (96) model, the overall Wald chi-square was 43.20, and if
363 (95) LAEF was added to the model, the overall Wald
371 (97) chi-square was 44.61, p ⬍ 0.05 for difference.
Receiver-operator characteristic curves are dis-
played in Figure 3. The AUC was 0.57 for LAmax,
0.74 for fractional change, and 0.66 for LAEF. Only
1084 Kühl et al. JACC: CARDIOVASCULAR IMAGING, VOL. 4, NO. 10, 2011

Prognostic Value of Left Atrial Function OCTOBER 2011:1080 –7

Table 2. Unadjusted Predictors of All-Cause Mortality

Survivor All-Cause Mortality

(n ⴝ 349) (n ⴝ 35) Wald HR 95% CI p Value
Age, yrs 60 ⫾ 12 71 ⫾ 7 24 1.09 1.05–1.13 ⬍0.001
Female 86 (25) 6 (17) 1 1.50 0.63–3.60 0.33
Hypertension 171 (49) 20 (57) 1 1.43 0.73–2.80 0.29
Diabetes 52 (15) 9 (26) 3 1.86 0.87–3.97 0.11
Previous myocardial infarction 74 (22) 11 (32) 2 1.69 0.79–3.30 0.19
Vessel disease (0, 1, 2, 3, or LM) 76 (22)* 16 (46)* 12 1.80 1.29–2.64 ⬍0.001
Left ventricular ejection fraction, % 59 ⫾ 12 52 ⫾ 14 10 0.96 0.94–0.99 0.003
Troponin T maximum, ng/ml 0.8 ⫾ 1.2 1.2 ⫾ 2.3 2 1.15 0.96–1.37 0.14
Killip class ⱖ2 33 (9) 12 (34) 19 4.40 2.17–8.77 ⬍0.001
LA maximal volume index, ml/m2 55 ⫾ 11 58 ⫾ 14 2 1.02 0.99–1.05 0.12
LA minimal volume index, ml/m2 30 ⫾ 10 37 ⫾ 15 16 1.05 1.02–1.07 ⬍0.001
Fractional change, % 46 ⫾ 9 37 ⫾ 11 29 0.92 0.90–0.95 ⬍0.001
Cyclic change, ml/m2 25 ⫾ 5 21 ⫾ 5 18 0.90 0.85–0.95 0.001
Reservoir volume, ml/m2 11 ⫾ 4 10 ⫾ 3 1 0.95 0.95–1.04 0.28
Reservoir fraction, % 20 ⫾ 7 18 ⫾ 6 3 0.11 0.01–1.84 0.10
LA ejection fraction, % 33 ⫾ 8 26 ⫾ 10 22 0.92 0.89–0.95 ⬍0.001
LA stroke volume, ml/m2 14 ⫾ 4 12 ⫾ 4 11 0.85 0.78–0.93 0.001
Values are mean ⫾ SD or n (%). *3-vessel or left main stem (LM) disease.
CI ⫽ confidence interval; HR ⫽ hazard ratio; LA ⫽ left atrial.

AUC for fractional change was significantly higher than tion, we made a subgroup analysis of 138 patients
AUC for LAmax (p ⫽ 0.018). with 1-vessel disease, and tested whether the culprit
To determine whether the location of the infarct- location in the left anterior descending coronary
related region had any influence on the LA func- artery, left circumflex coronary artery, or right

Figure 2. Kaplan-Meier Plots

Mortality in the study population stratified in tertiles of left atrial size and function.
JACC: CARDIOVASCULAR IMAGING, VOL. 4, NO. 10, 2011 Kühl et al. 1085
OCTOBER 2011:1080 –7 Prognostic Value of Left Atrial Function

Table 3. Univariate and Adjusted LA Predictors of All-Cause Mortality According to Standard Deviations of the LA Variables

SD Univariate HR 95% CI p Value Adjusted HR 95% CI p Value

LA maximal volume, ml/m2 11 1.27 0.94–1.71 0.120 1.06 0.76–1.47 0.53
LA minimal volume, ml/m2 11 1.61 1.27–2.04 ⬍0.001 1.31 0.96–1.79 0.08
Fractional change, % 10 0.47 0.36–0.62 ⬍0.001 0.65 0.45–0.94 0.02
Cyclic change, ml/m2 6 0.46 0.36–0.65 0.001 0.68 0.47–0.98 0.04
LA ejection fraction, % 9 0.47 0.35–0.63 ⬍0.001 0.63 0.44–0.91 0.01
LA stroke volume, ml/m2 4 0.55 0.38–0.80 0.001 0.64 0.44–0.92 0.02
Adjustments were made for age, left ventricular ejection fraction, Killip class, and number of diseased coronary vessels.
Abbreviations as in Table 2.

coronary artery was associated with different values whereas LAmin is determined by a combination of
for fractional change and LAEF; no difference intrinsic LA contractility and the load the LA faces
between the groups was noted (fractional change (LV effective chamber compliance and retrograde flow
p ⫽ 0.47, LAEF p ⫽ 0.17). We also made an into the pulmonary veins determined by pulmonary
analysis of the left anterior descending coronary venous capacitance). Finally, fractional change, which
artery versus non–left anterior descending coronary describes the maximal change in LA volumes relative to
artery and found no difference between groups LAmax, can be regarded as the sum of the numerous
(fractional change p ⫽ 0.43, LAEF p ⫽ 0.22). intrinsic ventricular and atrial properties discussed.
Despite this complexity, the clinical relevance of
DISCUSSION the LA imaging has been derived almost exclusively
from measurements of LAmax or merely maximal
To the best of our knowledge, this is the first study diameter assessed by 2-dimensional or M-mode
that has investigated the prognostic information of echocardiography. Clearly, this may not encom-
LA size and function assessed with MDCT in acute pass the full potential of prognostic information
coronary syndrome. The study suggests in a popu- of the LA.
lation with NSTEMI that LA functional measures are In agreement, the present study demonstrates
superior to LA size to predict outcome. This association that impaired LA function with reduced fractional
remained after adjustment for known risk factors of change and LAEF were independent predictors of
outcome including age, LVEF, and Killip class. mortality in low-risk patients with NSTEMI after
LA size and function. During ventricular systole, the adjustment for known risk factors. Moreover, the
endocardium undergoes significant radial displace-
ment, and as a result of contraction of longitudinally
oriented myocardial fibers, the atrioventricular plane is
pulled towards the apex of the heart. This will cause
stretching of the LA, augmenting filling of the atrium.
LV active relaxation starts in late systole, which
together with elastic recoil results in rapid early ven-
tricular filling and return of the atrioventricular plane
to the resting level. Consequently, the LA will rapidly
return to a smaller volume during early LV filling.
With subsequent diastasis, there is no wall motion,
and the atrium and the ventricle form a single cham-
ber with equalization of LA and LV diastolic pres-
sures. During this phase, almost no changes in LA
volume will occur. Only during the final portion of
ventricular diastole, atrial systole generates energy with
contraction and subsequent additional LV filling. On
the basis of this, LAEF will reflect the difference in
Figure 3. Receiver-Operator Characteristic Curves
LA volume from the volume at the end of diastasis
Receiver-operator characteristic curves for fractional change, left atrial
and at the end of atrial contraction relative to diastasis
ejection fraction, and left atrial maximal volume, demonstrating the
volume. The diastasis volume is, as discussed, depen- ability to predict all-cause mortality after 2 years follow-up.
dent on LV diastolic pressure and LV function,
1086 Kühl et al.
Prognostic Value of Left Atrial Function
prognostic significance of fractional change and
LAEF contained incremental value to LAmax.
The pathophysiological link between reduced LA
function and adverse clinical outcome cannot be di-
rectly elucidated from the present study. However, in
a previous study, Torabi et al. (12) found in a consec-
utive population of 896 patients that 84% of deaths
occurring during follow-up were preceded by heart
failure at some point. The development of symptom-
atic heart failure (shortness of breath on exertion) in
patients with NSTEMI requires LV filling pressures
to be elevated; the cause of this may be a complex
interplay of multiple factors including myocardial
ischemia, neurohormonal activation, renal failure, left
ventricular remodeling, hypertrophy, and pre-existing
decrease of effective chamber compliance. All of these
factors would be anticipated to affect atrial size and
contraction. The present results and the results of a
previous hypothesis-generating study (8), where we
found that clinical signs of heart failure are associated
with impaired LA mechanical function (fractional
change and LAEF) to a greater extent than
LAmax, concur with this theory. Impaired LA
function could perhaps be interpreted as an early
morphological manifestation for increased risk of
developing heart failure and, eventually, death.
Thus, although it is speculative, we believe that
impaired LA function is a risk factor for the
development of heart failure and that this could
provide the link to poor prognosis.
Regardless of the mechanism responsible for the
predictive value of LA functional imaging, an im-
proved prognostic evaluation could be clinically
useful. Further studies are needed to explore the
potential clinical benefits of LA functional imaging.
In the present study, LAmax was only a weak
predictor of outcome as opposed to previous studies
where LAmax on echocardiography has been re-
ported to be an important predictor of outcome.
Although the present study provides no direct
insight into this discrepancy, it could likely be
caused by different risk profiles in study popula-
tions. Patients with increased risk due to renal
dysfunction, hemodynamic instability, and so on
were excluded from the present study, leaving a
population with a considerably lower risk profile and
an a priori lower likelihood of presenting with an
enlarged LA than previous echocardiographic studies.
Possibly this explains that LAmax is less potent in the
present study in predicting outcome. In addition,
differences in defining LA volume on echocardiogra-
phy and MDCT may have influenced the results.
JACC: CARDIOVASCULAR IMAGING, VOL. 4, NO. 10, 2011
OCTOBER 2011:1080 –7
Study limitations. In the present study, patients at
the highest risk were not enrolled, thus the study
describes a low-risk group without cardiac arrhyth-
mias or renal dysfunction suitable for MDCT
scanning. Accordingly, the present results may not
be generalized to the average NSTEMI population.
However, this may emphasize 2 important points.
First, it may explain that we do not find a significant
relation between LAmax and survival. LAmax has
previously been shown to be a powerful predictor in
myocardial infarction patients with more comorbid-
ity and higher mortality rates (4,5). Second, this
seems to emphasize that LA functional values are
sensitive predictors of mortality.
To measure LA size and function, we used retro-
spectively gated MDCT scanning. MDCT has high
spatial resolution, but lower temporal resolution than
magnetic resonance imaging and echocardiography,
which could affect the precision of MDCT. However,
several studies have consistently demonstrated very
good agreement and correlation between MDCT and
magnetic resonance imaging, and good correlation
between MDCT and echocardiography when mea-
suring LA size and function (13–17).
In contemporary clinical cardiac MDCT imaging
implementing prospective data acquisition, the use
of retrospective gating is limited because of the
relatively high radiation exposure. Accordingly,
functional information may not be routinely avail-
able in future MDCT examinations of low-risk
patients. LA size and functional values, however,
may be assessed accurately with both magnetic
resonance imaging (18) and promisingly also with
2- and 3-dimensional echocardiography (19 –21).
Echocardiography was performed at referring
hospitals, and not according to a specific protocol,
on multiple different ultrasound systems with focus
on assessment of LV systolic function and detection
of left-sided valve disease. However, unfortunately,
no systematic assessments of LV diastolic function
or LAmax were available.
We had four obvious explanatory variables—a
priori known predictors of death, which were sig-
nificant in univariate analysis—for a multivariable
regression model: age, Killip class, LVEF, and
number of diseased vessels. This number of vari-
ables is in the higher end of what is statistically
reasonable with 35 events, and the results of the
multivariable analysis should be interpreted with
appropriate caution. The low number of events
prevented us from including other interesting vari-
ables in the models, which may have decreased the
prognostic utility of the LA variables.
JACC: CARDIOVASCULAR IMAGING, VOL. 4, NO. 10, 2011 Kühl et al. 1087
OCTOBER 2011:1080 –7 Prognostic Value of Left Atrial Function

CONCLUSIONS patients that we may be able to risk-stratify with

The present study demonstrates that impaired LA
function in terms of reduced LA fractional change
and LAEF predict a poor prognosis in low-risk
patients with NSTEMI, even after adjustment for
conventional risk factors. Furthermore, the prog-
nostic significance of fractional change and LAEF
contained incremental value to LAmax. Measure-
ment of LA function could serve as a sensitive tool
for early risk stratification in apparently low-risk
patients with NSTEMI. Further studies should
reproduce these results in other patient categories
with coronary artery disease to explore the extent of
this method, preferably also using echocardiography
or magnetic resonance imaging.
Acknowledgments
The authors thank research radiographer Tina
Bock-Pedersen and Bettina Løjmand, RN, for ex-
cellent technical and logistical assistance.
Reprint requests and correspondence: Dr. J. Tobias
Kühl, Department of Cardiology, 2012, the Heart
Centre, Rigshospitalet, University of Copenhagen,
Blegdamsvej 9, 2100-Cph, Copenhagen, Denmark. E-mail:
Tobiaskh@gmail.com.

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Key Words: computed
tomography y left atrium y
myocardial infarction.